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Traumatic Brain Injury Is Under-Diagnosed in Patients with Spinal Cord Injury

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Traumatic Brain Injury Is Under-Diagnosed in Patients with Spinal Cord Injury J Rehabil Med 2007; 39: 622–626 ORIGINAL REPORT TRAUMATIC BRAIN INJURY IS UNDER-DIAGNOSED IN PATIENTS WITH SPINAL CORD INJURY Anu Tolonen, LicPsych1, Jukka Turkka, MD, PhD1, Oili Salonen, MD, PhD2, Eija Ahoniemi, MD1 and Hannu Alaranta, MD, PhD1 From the 1Käpylä Rehabilitation Centre, Finnish Association of People with Mobility Disabilities, and 2Department of Radiology, Helsinki University Hospital, Helsinki, Finland Objective: To investigate the occurrence and severity of trau- bilitation, vocational planning and psychosocial survival of matic brain injury in patients with traumatic spinal cord patients with SCI (2–7). After SCI, paraplegia or tetraplegia injury. alone represents the onset of a massive change in the life of Design: Cross-sectional study with prospective neurological, any individual. In addition, most patients with SCI experience neuropsychological and neuroradiological examinations and medical problems, including neurogenic bladder and bowel, retrospective medical record review. loss of sensation, spasticity, pain, sexual dysfunction and Patients: Thirty-one consecutive, traumatic spinal cord in- skin problems. However, from the perspectives of vocational jury patients on their first post-acute rehabilitation period planning, supportive interventions and psychosocial outcome, in a national rehabilitation centre. concomitant TBI is a central factor to be considered. Methods: The American Congress of Rehabilitation Medi- TBI produces marked disturbances in cognitive and emo- cine diagnostic criteria for mild traumatic brain injury were tional functioning, e.g. fatigue, problems in attention, con- applied. Assessments were performed with neurological and centration, memory, and judgement, irritability, emotional neuropsychological examinations and magnetic resonance lability, and acting in socially inappropriate ways. Patients imaging 1.5T. Results: Twenty-three of the 31 patients with spinal cord in- with SCI with concomitant TBI are at risk for a complicated jury (74%) met the diagnostic criteria for traumatic brain rehabilitation process and unfavourable outcome if TBI is not injury. Nineteen patients had sustained a loss of conscious- recognized and the rehabilitation approach modified. ness or post-traumatic amnesia. Four patients had a focal In SCI, because the enormous physical injury is a focus of con- neurological finding and 21 had neuropsychological findings cern, the basic indicators of TBI, including loss of consciousness apparently due to traumatic brain injury. Trauma-related (LOC), post-traumatic amnesia (PTA), neurological symptoms magnetic resonance imaging abnormalities were detected in and signs due to TBI, and neurobehavioural changes, may go 10 patients. Traumatic brain injury was classified as moder- undetected and undocumented. Furthermore, patients with a ate or severe in 17 patients and mild in 6 patients. Glasgow Coma Score (GCS) (8) of 13–15 may also suffer from Conclusion: The results suggest a high frequency of trau- severe TBI (9), and often structural damage cannot be detected in matic brain injury in patients with traumatic spinal cord conventional neuroradiological examinations, such as magnetic injury, and stress a special diagnostic issue to be considered resonance imaging (MRI) despite brain injury (10, 11). Altered in this patient group. mental status, e.g. fatigue, information processing problems, and Key words: traumatic brain injury, spinal cord injury, co-occur- changes in behavioural and emotional regulation, can be misin- rence, rehabilitation. terpreted as post-anaesthesial sequelae, effects of medication, or J Rehabil Med 2007; 39: 622–626 a psychological reaction to a massive life change. In the systematic studies examining the co-occurrence of Correspondence address: Anu Tolonen, Käpylä Reha- TBI in traumatic SCI, the prevalence was estimated to be bilitation Centre, PO Box 103, FI-00251 Helsinki, Finland. 40–60% (2–7). However, only 1 or 2 indicators (LOC, PTA, E-mail: [email protected] neuropsychological deficits) have been used when diagnosing Submitted September 13, 2006; accepted April 19, 2007. TBI. Previous studies have not combined neurological, neuro- psychological and neuroradiological methods in evaluating the occurrence and severity of TBI within a SCI population. INTRODUCTION The aim of this study was to investigate the occurrence and severity of TBI by using neurological, neuropsychological and Traumatic spinal cord injuries (SCI) typically result from neuroradiological examinations in patients with traumatic SCI high kinetic accidents such as falls or traffic accidents. As admitted to the rehabilitation centre. traumatic brain injury (TBI) occurs in similar circumstances, these neurotraumas can frequently be assumed to be present concomitantly. In fact, most cervical SCIs are secondary to METHODS indirect forces transmitted to the spine through the head (1). The study was carried out between April 2000 and September 2001 at TBI has been suggested to be a major concern in the reha- the Käpylä Rehabilitation Centre, Helsinki, Finland, according to the J Rehabil Med 39 © 2007 Foundation of Rehabilitation Information. ISSN 1650-1977 doi: 10.2340/16501977-0101 TBI in patients with SCI 623 principles of the Declaration of Helsinki and with the approval of the local Table I. Classification of patients according to spinal cord injury and ethics committees. Informed consent was obtained from all patients. American Spinal Injury Association (ASIA) Impairment Scale (AIS) There are no data on the actual incidence of traumatic SCI in Finland. More than 90% of all patients with traumatic SCI with paraplegia or AIS tetraplegia in Finland are referred to the Käpylä Rehabilitation Centre A B C D Total upon conclusion of the acute phase. The incidence of referred patients Tetraplegia 3 4 7 2 16 is 1.1/100,000 inhabitants per year. Paraplegia 9 2 3 1 15 Total 12 6 10 3 31 Patients Thirty-one (1 female and 30 males, mean age 36 years) of 80 consecu- A: Complete: no motor or sensory function is preserved in the sacral tive patients with traumatic SCI on the first post-acute rehabilitation segments S4–S5. period fulfilled the following inclusion criteria: (i) age 16–54 years; B: Incomplete: sensory but not motor function is preserved below the (ii) no history of prolonged alcohol or substance abuse; and (iii) no neurological level and includes the sacral segments S4–S5. history of psychiatric or cerebral disorder including TBI. Because the C: Incomplete: motor function is preserved below the neurological neuropsychological test battery is appropriate only for adults over 16 level, and more than half of key muscles below the neurological level years of age, younger patients were not studied. Also, the patients over have a muscle grade less than 3. 54 years of age were excluded because age-related non-specific changes D: Incomplete: motor function is preserved below the neurological may confound the MRI interpretation. The exclusion criteria (ii) and (iii) level, and at least half of key muscles below the neurological have a were used to ensure that neuropsychological and neurological examina- muscle grade of 3 or more. tions did not reflect these possibly pre-existing conditions. Forty-nine of the original 80 patients were excluded for the follow- ing reasons: age under 16 years or over 54 years (n = 26), prolonged Neurological examinations alcohol or substance abuse (n = 11), psychiatric disorder (n = 3), The neurological examination was performed by the neurologist (JT), previous cerebral disorder (n = 1), insufficient knowledge of Finnish who was unaware of the results of neuroradiological and neuropsy- or Swedish (n = 4), refusal (n = 2), rehabilitation period too short chological examinations. This examination included an evaluation (n = 1) and Hallowest not suitable for MRI (n = 1). of any neurological symptoms and signs due to TBI, such as cranial The mean period of education of the patients was 12 (range 8–16) nerve dysfunction, pyramidal and extrapyramidal signs, sensory hemi- years. SCIs were caused by traffic accidents (n = 14; 46%), falls syndrome, and cerebellar signs based on medical records, patients’ (n = 13; 42%), diving accidents (n = 2; 6%), and other causes (n = 2; history and clinical examination. The routine pattern of examination 6%). Twelve patients had complete lesions of the spinal cord according comprised sensory evaluation, muscle tone and power measurements to the impairment scale by American Spinal Injury Association (ASIA) in the upper extremities of patients with paraplegia, and deep tendon (12, 13). Patients’ spinal cord injuries are presented in Table I. reflex and finger-to-nose testing. GCS at the time of injury or at admis- sion and any alteration of consciousness after the injury were evalu- TBI diagnostic criteria ated retrospectively from the medical documents by the neurologist. The diagnostic criteria for mild TBI diagnostics by the American Also, secondary brain injuries and other complications affecting brain Congress of Rehabilitation Medicine (14) were applied (Table II). function, such as hypoxia, massive bleeding and medications, were The criteria include any of the following: (i) any period of LOC; (ii) evaluated by the same neurologist. The neurological examinations any PTA; (iii) any alteration in mental state; and (iv) any focal neuro- were performed 17.8 weeks (mean; standard deviation (SD) 11.5) after logical finding (transient or permanent) due to TBI. To ascertain that the injury. The ASIA impairment
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